The Emergency Room Visit & Money

*this post may be specific to the U.S. and may not apply to countries where universal health care is in effect


No matter what your financial situation is, when your loved one (or you) is critical and needs life-saving care, one of the last things you think about is money. After all, you have insurance (hopefully) so it should all be covered, right?

Surprise, surprise! Shortly after the emergency room nightmare the bills start coming in and you call the hospital billing office, "Why didn't you bill the insurance company?" That's when it's explained to you that even though the hospital participates in your insurance network not all of the doctors (hospitalists and consultants) or services (like lab-work, etc.) do and your insurance company denied the claim. Yes it seems ridiculous to you, you probably never even requested your own specialists, you probably weren't even consulted as to which specialists where requested by the hospital — and, like me, you were never asked if you were able to pay for these necessary consultations.

All you wanted was for your loved one to live!

Okay, that is what happened to us that night Mark was diagnosed with a stroke. Doctors and technicians were coming in and out for the first few hours, I had no idea which were hospital doctors and which were on-call specialists. All I knew was that a doctor (I can't even recall which one) had just told me that my husband had a stroke and "the next 48-hours would be critical".

When the bills started coming in and I saw the word "denied by insurance" I was puzzled, furious and scared. First of all Mark had already surpassed his deductible for the year so there shouldn't even be co-pays that we were responsible for; secondly these were doctors that a participating hospital sent in to treat my husband. I started making phone calls, first to the hospital billing, then to the medical services billing for the individual doctors, and then to a pretty unresponsive insurance company (I am purposely withholding the name of the insurance because I have NO nice things to say about them). What I managed to find out from these calls was that since the doctors were out of network the insurance company denied the claims.

I scoured through the insurance company manual and found a vague statement about emergency room treatment, but I still couldn't get a definitive answer from the company itself. That's when I called my state's Dept. of Insurance/Finance and found out about "Surprise Bills". New York and several other states have rules regarding this coverage (check with your local state to find out) AND most insurance companies will cover Emergency Treatment even if out-of-network so long as a network provider was not readily available. In N.Y. I had to download Surprise Bill Assignment forms and submit to both the debt-ee and the insurance company; these bills were paid after all.


Uninsured?

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. The ER MUST determine if there is a TRUE emergency and may not turn you away or transfer you to another facility until and unless you are medically STABLE.

There are many hospitals across the nation that may continue to provide care even after you are stable IF they provide "Charity Care". You need to contact the hospital (a patient advocate may be the best resource) to apply; hospitals are generally the best resource for this information. New Jersey and many other states have government agencies that provide more information about Charity Care. You will most probably need to provide proof of NO insurance and proof of income. 

For non-emergency care there are many FREE clinics that can provide low or no cost care depending on your financial situation. Always go to the hospital in a TRUE emergency.



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